New Patient Form | Dr Foti Sofiadellis

New Patient Form (ALL patients to complete)

CONFIDENTIAL PATIENT INFORMATION

Please note that your information is saved as you enter it.

Welcome to our practice. Our aim is to provide you with the best possible healthcare. Please complete all sections and read the Personal & Health Information Consent section at the end of this form. If you have any queries, please speak to one of our team members or Dr Foti.

Personal Details

MsMissMrsMrMasterDrProfOther

Please Select:

RetiredEmployedOther

Medicare Details

NoYes

I consent to be bulk billed, where applicable*

Do you have Private Health Insurance? Please select:

NoYesExtrasHospital

Concession Card

WhiteGold

Privacy

Do you consent to communication being sent to your family doctor or GP?

YesNo

General Practitioner's details (only complete this section if your GP was not your referring doctor)

Are you happy for information to be given to your next of kin over the phone?

YesNo

Referral Source

What is the reason for being referred to Dr Foti Sofiadellis?

How did you hear about Dr. Foti Sofiadellis?

GoogleReferred By DoctorPersonal RecommendationOther

MEDICAL QUESTIONNAIRE

Medical History

To ensure optimal medical and surgical care, it is very important that you answer the following questions thoroughly and honestly.

To calculate your BMI please click here: BMI Calculator

BMI: Dr. Foti does not operate on patients who have a BMI over 30, due to the increased risk of post-op complications.

Please get in touch with us if this applies.

Have you ever experienced/undergone any of the following:

Heart AttackPacemakerChest PainCardiac StentStrokeDVT or Pulmonary EmbolismTIA (mini stroke) Bypass SurgeryEpilepsy Or SeizuresAsthmaDiabetes

If yes to diabetes, how is it controlled:

DietTabletsInsulin Injections

Have you ever been treated for, or diagnosed with (tick if applicable):

AnxietyDepressionPTSDBipolarBody DysmorphiaEating DisorderPsychosis

Are you currently a smoker?

NoYes

Do you have Allergies

YesNo

Medications

Do you take any blood thinning medications, such as:

AspirinWarfarinPlavix/Clopidogrel

Surgery

Have you had any previous surgery?

YesNo

PRIVACY

Personal and Health Information Consent

We respect your right to privacy and take our privacy obligations seriously. We comply with the Australian Privacy Principles, found under the Privacy Act 1988 (Cth). Our Privacy Policy can be obtained by requesting a copy from reception or from our website.

We require your consent to collect personal information and health information about you. Please read this information carefully, and sign where indicated below.

We collect information from you for the primary purpose of providing you with our healthcare services. We require you to provide us with your personal and health information and your full medical history so that we may provide our services to you. We will also use the information you provide in the following ways:

To appropriately manage our practice, including undergoing conduction audits and accreditation processes, managing billing and training staff.
To effectively communicate with third parties, including Medicare Australia, private health insurers, government departments, and other practitioners involved in your healthcare.

During the post-operative period, if you have any post-operative complications, you may choose to send us questions or clinical photos for your nurse and Dr. Foti to review. In signing this form and choosing to transmit images or questions to us via email or mobile phone post-operatively, you acknowledge that these images may be transmitted to relevant clinicians via their devices (phones, iPad, email) for them to urgently review for post-surgical care as required.

PHOTOGRAPHY CONSENT

Clinical photos may be taken at your consultation and will form part of your clinical record. Images will be accessible to our staff for clinical purposes. Photos are stored in a secure server, compliant with the Australian Privacy Principles.

Patient Signature:

Please tick to acknowledge that we contact our patients via email and SMS to confirm appointments, send booking information and patient education content. Please note that most email and SMS services are not encrypted, and therefore not protected from interception or hacking. If you do not consent to us contacting you via email or SMS, please contact our clinic directly by calling (03) 7067 9688 before completing your form, so we can establish alternative ways of contacting you.*

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